2018年大選前夕 - 個人聲明

近來在我社運朋友圈子里沸沸騰騰辯論著下屆大選的投票態度和動向。一邊大力鼓吹選民出來投票並且投票給希望聯盟(Pakatan Harapan)以保住國會至少三分之一的在野陣線議席；另一邊廂則批評前者的策略和注重結果的功利主義，同時對老馬加入後的希聯深感懷疑并大力抨擊。他們未必鼓勵人投廢票，但堅持投票是個人的自由，以目前的局勢現況若有人要不出來投票、投廢票或投第三黨，也不能怪他們。

我本人因為近這兩個月工作事忙，沉寂了一陣子。我覺得是時候發表自己的聲明。

1. 我不再相信人治政治。政壇上哪個陣線或政黨即使有再多的‘好人’或/和‘有能力’的人，不等同於該政黨的政綱方針。如果他們沒有推出體制上明顯的政治和司法改革，我很難被說服哪個更好（或足夠好），縱使我相信在最好的情況希聯上台執政會有小幅度的修改式改革。我有讀書，所以更有要求，不要騙我。

2. 目前希聯仍是權宜之幫，沒有明顯的政治方向，甚至沒端出值得期許的體制改革藍圖。他們代表什麼？我不清楚。我不能接受希聯的現狀，除非未來有新的正面變化。如果有人叫我為目前的希聯背書叫大家都投票給他們，對不起，我不願意。

3. 我仍會呼籲大家出來投票支持那些他們認為表現良好和有理想原則分寸的議員和政治人物。我不會投廢票（雖然我的票在梳邦再也其實一點都不‘值錢’），因為我仍滿意目前我的國和州議員。假設我的選區出現極具爭議性或負面的希聯議員，我本身很有可能就會把票投給第三黨或不投票（投給國陣目前仍難以想象...因為少有非常傑出值得支持的人選）。

4. 假設希聯執意要推薦有問題（或‘yes (wo)man’）的候選人，如果在當地不受歡迎而被懲罰落選了，那不是民意嗎？政黨難辭其咎，選民不需覺得自己為他們不認同的候選人和政黨負責。

5. 現在的球是在希聯的腳下，到底他們還要繼續分化公民社會的支持，還是能代表一個真正的希望和選擇團結凝聚各階層各社區的支持（而不是純粹是累積‘反對（國陣）票’的情緒票）。很多社運份子甚至上屆大選的民聯中堅支持者失望洩氣了。我認為其中一邊的社運者能明白另一邊的苦衷和想法，更重要的是，促使希聯在下屆大選來臨之前大力改進，把reform agenda（政改方案）拿出來。希聯的現狀是飽受另一邊社運份子批判的重點，無論你要他們怎樣改觀都不簡單，畢竟解鈴人還需繫鈴人。

對於馬哈迪領軍希聯這事...

我其實想不直接地表露出以下幾點：

1）希聯推出馬哈迪領軍迎戰下一屆大選，很可能不是最佳策略。他的形象是希聯的正與負資產--對他的印象感到負面的不能說少（畢竟他在任的時候得罪和傷害的人多）。但他目前扮演的角色正是分裂性的，從近來的中英文評論圈子裡可反映出來。

2）這樣下去，馬哈迪這個人的過去和現在肯定會是大選競選期間的主題（國陣的主攻），那麼有關國家政治改革和未來的希望論述還能展開嗎？

3）對於不太認識他的年輕人，馬哈迪真的有號召力和吸引力？

4）我正擔心著希聯的競選宣言會是民粹的...自從土團黨加盟希聯後，政策路線和發展的去向，讓我擔憂。

5）我舉例了很多國外的年輕領袖可擔當國家領導高職。我認為如果政黨敢敢推出沒有太多歷史包袱，以及能營造新政論述的年輕領袖，或許可以出奇制勝。我對505大選的觀察是，年輕人的影響力是巨大的，那時的民聯競選的驅動力(momentum)主要來自年輕人熱血地投入。

6）我也看到Jeremy Corbyn對年輕人的政治動員和競選運動的興論影響力。雖然Jeremy Corbyn不是年輕人，但他的想法絕對符合年輕人的期待和要求。所以，領袖的年齡不一定是個問題，而是他說了和做了什麼，許我們這一代和下一代什麼未來？

7）理智和情感上我不願讓國陣奪回國會的2/3席位，但這次球真的在希聯腳下...我沒有那麼大的影響力去幫他們扳回一城，就看他們的策略和智慧了。

8）我跟一些人說過了，我不大會‘賣’不太好的產品。我要怎樣賣，也得過得我自己良心這關。

9）國陣的競選宣傳可以避開納吉而不談嗎？反過來希聯亦是如此。

政治要與年輕人接軌

截止2017年第二季，符合資格但卻沒去登記的選民總共有370萬人，其中243萬人年齡介於21至30歲之間。同時參考該年齡組的國家人口統計，發現差不多每三人就有一人沒去註冊選民。到底為何這些年輕人不熱衷登記為選民，或換句話說，不准備履行最基本的民主義務？

根據默迪卡民調中心和“我的國土”(Watan)非政府組織的聯合民調顯示，高達七成的年輕人對政治冷感，主要是覺得政治太複雜和不認為自己能影響政府的決定。雖然如此，卻有大約六成的受訪者認為國家正走往錯誤方向，通貨膨脹和貪污問題是他們最關注的兩大課題。這間接說明，年輕人不是不懂或不關心政經社會課題，只是覺得被政黨政治冷落邊緣化。這種印象不是舉辦多幾場TN50國家轉型計劃公民大會就能逆轉的。

上屆大選創下了大馬史上最高投票率的記錄。年輕人曾對政改和政黨輪替滿懷熱忱和期待，“505換政府”和“Ini kali lah”(就是這一次)的口號喊得特別響亮，造就在野黨聯盟取得歷來最高的得票率（51%）。可惜，由於選舉制度的不公，結果在野黨斬獲的議席席次不成正比，與‘改朝換代’擦肩而過。接下來的幾年，政局瞬息萬變：卡巴星和聶阿茲相續過世、安華入獄、民聯瓦解、希望聯盟（希聯）和誠信黨誕生、馬哈迪退出巫統成立土團黨再到政治版圖重組由馬哈迪領導在野陣線。凈選盟大集會也辦了多兩次。

年輕人的政治冷感何來？

奈何，近來在野黨舉辦的政治集會人潮異常冷清，出席者更少見年輕人。我在想，年輕一輩的，是否跟得上并明白這些政局的變化和其中涵義？當中的這些演變有哪些與他們扯上關係？他們的想法，政治人物到底有多在乎？或許年輕人看到更多的是政治人物互相攻擊或大話胡扯，加強他們對政治的負面看法進而導致冷感。

若問年輕人是否要改變，或許他們會反問：“改變是什麼？”或“到底會有什麼改變？”。在野黨若認真，平時應該多集思廣益咨詢專家和收集民間的看法，并好好地作政策研究，以務求能端出進步、有方向與全方位的政改綱領。有了政策共識後，政治人物才能清楚并仔細地為選民勾畫政治改革的願景，說服選民為何要投選支持他們而不是為了反對另一方。所以，不止是年輕人，其他年齡階層的選民也很想知道，希聯承諾要帶來的改變會是什麼？比如說，在經濟、教育、交通、公共醫療、環境土地、言論自由、司法、公共服務官僚體制等，到底與國陣現有的政策有多大的分別？若政權改變，希联雖然要能在執政的短期內解決一些急迫的關鍵課題，但切忌為了討好各方而變得民粹迷失方向，更不好為了短期的政治利益而罔顧國家社會的中長期的發展和利益。

新政要有新臉孔新形象

除了政治改革的承諾，領導人的形象代表和價值觀也是許多年輕人觀望的重點。當一方提要推出‘新政’，而他們的領導整容卻由許多舊臉孔掛帥，似乎很難取信他人。試問當今年輕人，目前由馬哈迪領導的在野黨陣營，有沒有給他們帶來任何的政治期待和想象空間？

環顧近年來的國際政治，不少較為年輕的政治人物成功勝選擔任國內最高民選領導人。舉例來說，今年上任的就有37歲來自工黨的新西蘭總理傑辛達·凱特(Jacinda Kate Laurell Ardern)，41歲來自左派綠色聯盟的冰島總理卡特琳·雅克思(Katrín Jakobsdóttir)，39歲來自‘共和前進’黨的法國總統埃馬紐埃爾·馬克龍(Emmanual Macron)，以及2015年勝選時才43歲來自自由黨的加拿大總理賈斯丁·杜魯道(Justin Trudeau)。這些年輕領袖的冒現也順勢回應了當前選民欲看到政治新氣象和改變的渴望。同時，這也符合當地年輕人的政治想象和要求，期望他們的聲音更能貼近政治主流。

當然，年輕人不一定要支持較年輕的政治領袖。英國的工黨領袖傑里米·科爾賓(Jeremy Corbyn)就是一個好例子。他積極遊走全國聆聽并貼近大眾特別是年輕一輩，多次現身在年輕人為主的場合（比如說搖滾演唱會）。這種雙向和坦然的政見溝通能賦權選民，然後政治人物所提的想法和政策才會踏實接地以及與人民日常生活有關聯（relevance）。這不正彰顯民主的可貴嗎？

政治要與生活有關聯

所以要解除年輕人的政治冷感，就得讓政治打破藩籬重新與年輕人接軌，與他們的生活保持關聯。朝野政黨到底如何讓年輕人對政治有所期待和想象，覺得自己的心聲會被聆聽和尊重，并擁有發揮影響力的空間？若國內政治仍是幾位政黨高層在密室換馬的權力遊戲，很難怪民眾感到無奈和被疏離，甚至質疑政黨輪替會帶來的實質改變。

我不由得想象若由年輕領袖諸如努魯依莎等新形象領軍希聯迎戰下一屆大選，會不會更能掀起千層風浪，鼓舞動員更多年輕人積極參與助選？年輕人的精力以及在家庭和社區內的影響力，不容小覷。政治再不與年輕人接軌，難有改變。

刊登于《東方日報》東方文薈版2017年12月23日

The appeal of Islamic Democrats in Malaysia

TWO weeks ago, I participated in an international conference in Kuala Lumpur organised by the Istanbul Network, a group of think-tank leaders from Muslim majority countries.

During the Q& A session, I posed the following question to the panel: Why should non-Muslims support an Islamist party, whether in a Muslim-majority country such as Malaysia or in a country where Muslims are in the minority, if the party in question only has an exclusively religious agenda for the Muslim community? I did not get a direct response to the question, and this still lingers in my mind after the conference.

To be fair, many distinguished speakers presented many good papers which examined the history of democratic transitions, outlining the relationship between Islam and democracy and further looking at the socio-economic undercurrents behind such transitions.

Case studies on Islamic political parties and movements in different countries were also discussed. I appreciate the evolution in certain countries such as Tunisia and Turkey that witnessed political transitions from an Islamist party to a party of Islamic Democrats, in Ennahda and the Justice and Development Party (AKP) respectively.

One fundamental difference between many Islamist parties around the world and Malaysian ones, is that Malaysia has a large proportion of non-Muslims in the population which the Islamist parties, like it or not, need to interact with.

If an Islamist party only appeals to the Muslim community in Malaysia, it would restrict its political influence to parts of the country with very few non-Muslims.

This was the situation faced by PAS in the past when its influence was mostly limited to the northern and east coast states in Peninsular Malaysia.

For a party to win elections at the federal level in Malaysia, it has to be part of a coalition which has a broad support across all ethnic groups. Even if an Islamist party like PAS only wants to appeal to the Muslim community, its views and positions must be acceptable to other parties within the coalition, some of whom will definitely represent the views and aspirations of non-Muslims in the country.

Unless an Islamist party wants to stand apart from any political coalition, it has to take into account the perspective of non-Muslim voters. This is one important yardstick of democratic transitions, which is the consideration of the diverse voices of the people, even from those who do not support the party / coalition in power.

Given that the Muslim community does not live in isolation, the positive and negative impact of policy difference and public opinion have to be resolved by ‘Ijma’ or the consensus of the masses.

The concept itself already has ‘bottom-up’ democratic elements and it does not imply majority rule but a need to consider as well as respect minority rights. However, consensus building often needs reference to some form of common denominator among different community groups.

Thus, it is not an issue when an Islamist party brings in Islamic values in policy discussion, if the values are a common denominator shared and understood among all the communities. For that, the doctrine of Maqasid al-Shari’a has been well-received and applied in some places in the Muslim world as the guiding principle in response to multiple issues concerning public interest, ranging from economy, environment, health and even human rights.

This shows that religion could be a big part of the political discourse if it stays aligned and relevant to people’s daily life and societal functions, be it Islam, Christianity, Hinduism, Buddhism or other religions. No religious practices or values should be forcefully imposed on the people, whether they are believers or not.

In my opinion, what sows distrust among communities in Malaysia in present day, is the allegation or perception that one gets differential or preferential treatment over others. If an Islamist party is going to pit Muslims against non-Muslims, and in doing so, creates a siege mentality among the former, the ensuing result is a negative campaign which is based on fear and discrimination. This cannot go

far in winning over the middle ground which includes a sizeable non-Muslim population.

Worse still, this reinforces the negative perception that an Islamist party tries to divide the people based on religion and treat them differently. Thus, such appeals which are premised on religious exclusivism and exerting obligations and values on others, could prove to be detrimental to social cohesion and nation building.

However, this really needs not to be the case. Political Islam, as any other movement, has plenty of diverse ideas and means to achieve its goals. Post-Islamism is emerging as a reaction to the perceived failure of many ruling Islamist politics in the Muslim world at addressing fundamental citizen needs and expectations such as jobs, education and the provision of basic public services including rubbish collection and access to clean water.

Given that the world has liberalised through recent decades via the information technology revolution, any attempt to control thoughts and ideas by using the religious monopolist, puritan and statist approach will surely be meet with strong resistance. The changing trend in the socio-demographics of many of these Muslim countries will raise more questions on the views and roles of an Islamist party, especially among the younger generation who are growing up in an environment where information and networking is much more accessible compared to before.

Presently in Malaysia, Parti Amanah Negara represents the mainstream political variant of Islamic Democrats. I see the vast potential and the positive impact that their political movement can bring to Malaysia. Hopefully they will present and bring out a more wide-ranging and progressive political Islam discourse in Malaysia, to showcase that Islamic values could be universal, inclusive and meaningful to all.

After all, Christian Democrats in the western world have proved to be able to command broad support and govern in fairness to all citizens, why not Islamic Democrats? In that sense, why should non-Muslims NOT vote for such ideals from Islamic Democrats who can truly represent them?

Published at The Malaysian Insight, Voices, Dec 17, 2017.

Health check on the 2018 Budget

LAST Friday after prime minister and finance minister Najib Razak tabled the 2018 Budget, which he dubbed ‘the Mother of all Budgets’, my friends asked me what I thought about the budget allocation given to the Ministry of Health (MOH).

In my previous column article, I justified the reasons why the MOH should be given a larger budget allocation amounting to over RM28.5 billion (or >15% growth rate). The good news is that under the 2018 Budget, the MOH budget allocation has indeed increased to RM26.6 billion, albeit at slower growth rate of 7.2%.

As is the case with the Budget itself, this year’s Health allocation is historically largest and takes the highest share (9.5%) relative to the total Budget since 2009. In response to the announcement, both the health minister Dr S. Subramaniam and the health director-general Dr Noor Hisham Abdullah publicly expressed their satisfaction with the budget allocation. On a personal note, I was disappointed by the shortfall of about RM2 billion or half of the growth rate that I was expecting to see. As the saying goes: ‘the devil is in the details’, it is worthwhile to see if the government has genuinely put the Rakyat’s money where its mouth is. 

New development, bigger budget

From a first glance at the headlined items, it appears that the government is heeding the call to allocate more funds towards development expenditure. About half a billion ringgit, or a 37.9% increase in budget allocation, has been channelled to development, of which RM212 million was added to the budget for upgrade and expansion hospital facilities. Purchase of medical equipment and vehicles was topped up by RM244 million (Figure 1). It is certainly a welcome move and necessary action after the tragic fire incident at the Sultanah Aminah Hospital that took six lives last year.

In his Budget speech, Najib mentioned the fix for the wiring systems and even ambitiously announced plans to build new hospitals and wards (including one for the Pulau Pinang Hospital). Strangely, merely RM2.7 million in additional funding has been allocated to achieve these plans.

By right, we should be placing more emphasis on the operating budget, since it takes up 93.1% (RM 24.7 billion), a lion’s share of the total MOH budget. Over half, or 60.9%, of the operating budget is reserved for the salaries and wages for a workforce of 268,014 in total. The number of positions in the Health Ministry has increased by 30.2% from 2010-2018, while the amount paid for emoluments in 2018 has risen 144.6% compared to 2010. The health workforce is crucial in ensuring high standards of healthcare delivery, but this rise is only justifiable if the emolument rise converts to higher pay to retain quality talent.

Cut back on funding for supplies and services

Departments under the Medical Care (Perubatan) category will receive the largest amount RM13.2 billion, or a 53.4% of the total operating budget, followed by the Public Health (Kesihatan Awam) category (RM4.7 billion or 19.1%) (Figure 2). Worryingly, although the total sum of allocations for these two categories has increased compared to 2017, most of it is channelled towards emolument. Despite the functional importance of these two categories, the government has opted to cut back on funding for supplies and services for both categories (Figure 3). For Medical Care, the allocation for supplies and services shrank from RM5.17 billion in 2015 to RM3.92 billion in 2018, a difference of RM1.26 billion!

MP for Kampar Dr Ko Chung Sen rightly criticised the government on the RM65 million reduction in the allocation for the pharmacy and supplies division. It is a peculiar decision, given that many members of the public who engage the services of MOH hospitals or health clinics have long complained about the frequency of drug shortages. A reduced allocation certainly does not help to alleviate the drug demand burden. Therefore, when Najib announced that a sum of RM2.5 billion would be allocated for medical supplies and RM1.6 billion for consumable and medical support items, was he actually referring to an increased or reduced allocation?

Public health concerns

The other worrying budget reduction is related to the Disease Control and Public Health Pharmacy and Supplies divisions, which will receive RM22.4 million and RM35.6 million less respectively in 2018 for services and supplies, compared to this year.

This reduction is especially worrying for the Disease Control division, which has seen a declining share of allocations from RM402 million in 2011 to RM159 million in 2018. Unless one can prove that the services provided by this division have become substantially cost-effective, the decision to slash funding is controversial, in the backdrop of dengue and malaria outbreaks as well as the re-emerging threat of various vaccine-preventable infectious diseases.

Lastly, it is definitely timely to tackle the non-communicable diseases (NCD) via the KOSPEN programme, and the RM30 million allocation will prove useful to carry out a nationwide campaign. On the other hand, the Malaysia Health Promotion Board (MySihat) is a statutory body under the MOH that is also focused on health promotion, however it has received RM5.5 million annual budget for the past 3 years and past campaigns have been criticised for being rather ineffective.

It would make sense for KOSPEN to collaborate with MySihat for the NCD campaign and in doing so, hopefully they will be able to live up the programme name: ‘Healthy Community Empowers the Nation’. 

Published at The Malaysian Insight, Voices, Nov 5, 2017.

醫療旅遊對國人是利還是弊？

本週檳中對專欄的文章由我撰寫，我就寫有關醫療旅遊的研究心得。可惜主編放了一個相當‘聳/俗氣’的標題。我的文章是要探討醫療旅遊的利與弊。加上週五的預算案，財長納吉也宣佈撥款發展醫療旅遊，所以更值得我們關注這所謂的‘經濟領域’。

以下是我的文章，附上原標題和副題。

*****

醫療旅遊對國人是利還是弊？

近年来我国的百货物价上涨，再加上经济仍缓慢成长，中下阶层的人民频感生活压力。若不幸碰上疾病缠身，更是雪上加霜。要寻求治疗，不少公立医院人满为患已是司空见惯的场景。问题是，在檳城，即使求医者来到私人医院，也未必能如愿顺利就医。

一些私人医院採取领號码排队制度，竟传闻有跑腿代领號码的服务；另一些医院，即使有预约，或许也得等上一两个小时才能见到属意的专科医生。在檳城，尤其是在某些大型的私人医院，处处可见眾多的外籍医疗旅客一起排队等候见医生。笔者常听闻有人控诉这些旅客已侵佔了本地人的医疗资源，但也有些人发现要批评却有口难言因为担心会给人排外的印象。具体的政策还是得有人分析，到底医疗旅游业对当地人是利还是弊？

一个政策或商业活动若完全不利於所有人，大概不可能会有任何基础可持续下去。其实更该问的是，到底是谁会从中得利，和多少人受惠？

经济效益大

从国家经济的角度来看，医疗领域被纳入12个国家关键经济领域（NKEA）的其中一项。

仅是来自私人医院的收入，在2015年已贡献了国家90亿令吉，其中12.9亿令吉来自檳城。而同年的马来西亚医疗旅游理事会（MHTC）数据显示，私人医院从到访檳城的医疗旅客赚取了3.5亿的收入，相等於27%整体私人医院的总收入。对於檳州2015年州內总產值761亿令吉的经济体来说，来自私人医疗和医疗旅客的收入相当可观。

外籍医疗旅客和伴隨著的亲友，来到目的地除了往医院走一趟寻求护理治疗以外，还得安排膳宿和交通。所以传统上与旅游业相关的服务业，例如航空业、交通服务业、酒店饮食业和观光旅游业等都可能分得一份羹。

根据檳城环球旅游机构2016年度的《檳城旅客调查》统计，医疗旅客在檳城的平均消费是一般外国游客的2.2倍，而且將近3/4的受访者已重访檳城。所以，对从事旅游业的业者来说，他们对医疗旅客与亲友的到访趋之若鶩无需感到意外。

本地人有更高的服務要求

撇开旅游业不谈，医疗旅游业同时也增加了医疗护理相关的就业机会。2015年，檳城的私人医疗服务业就僱用了1万1143人，其中包括1118位医生和3928名护士。医疗旅游或许同时促使檳城私人医疗界增码投资，除了提升医疗设施，也增加医疗人力资源，凝聚最佳的专科医生和医护人员。

成果是，檳城的医生和护士对人口的比率比国內平均值和大多数州属还低，意味著檳城人拥有更多的医护人员提供服务。此外，根据2016年的另一份调查，有96.7%的受访者表示可以在住家的方圆5公里的涵盖范围內寻得公立和私立的医疗护理服务。

以上所提及的医疗发展好处，对正寻求医疗援助的当地人来说，他们会直接感受到吗？或许一些人认为在私人医院求医需付费，所以要求和期望就自然越高。2015年的《国家卫生和病態调查》报告透露，有高达9%的檳城人不满在私人医院的等候时间，另外55.1%的受访者不满其医药账单。这些给予私人医院「差劲」评价的檳城人比率，明显比全国平均值高出二至三倍。

比起门诊病人，住院病人通常所需的医护资源是最多的。檳城卫生局2016年的数据显示，檳城私立医院的住院人数（15万7495）高於公立医院（13万3095）。这与全国和其他州的比率趋向是相反的，如在2015年全国公立医院的住院人数是私人医院的2.5倍。

另外，MHTC的数据指出，医疗旅客来檳城的人数（不分门诊或住院者）从2011年的26万8600增至2016年的30万400，涨幅有大约40%。根据檳城研究院尚未公佈的研究分析显示，横跨癌症、循环系统（包括心臟病和中风）和肌肉骨骼系统三大疾病类別，可见医疗游客的住院人数和比率自2009年起逐年增加。

儘管住院比率下降，本地人对私立医院的床位医护需求依然有增加。如此的趋势延伸下去，倘若医疗旅客增长的速度更快但本地人的需求也同时增高，医院却又无法在硬体设施和人力资源方面跟得上，人民对医疗旅游政策的不满积怨就更深。

挖角专科医生

一些私人医院常强调他们能召到不少长期在海外服务的资深专科医生回国，笔者相信这不可能是医院的一般作业，因为这类的大马籍海外专才毕竟还是非常有限，有念头要回国的或许更少。

根据笔者的研究发现，儘管在公立医院服务的医生总人数较多，私立医院拥有的专科医生数目几乎是公立医院的两倍。

由於我国法律的约束，院方不能够隨意或轻易地聘请外国专才，只好从我国有限的人力资源里（不管是来自公立或其他私立医院）挖角一些资深的医生。既然是零和博弈，难道檳城私人医院的挖角就不会影响到公立医疗和其他州属的专科医生人手分配吗？

无可否认，医疗旅游业带来的经济效益是正面的，但这行业伴隨著的社会挑战不小，尤其是如何规划得体应付逐年增长的医疗旅客和本地人的医疗需求。再说，若医院对待医疗旅客和本地人都一视同仁，假设本地人已不满其医疗服务了，难道医疗旅客会满意？


刊登于《東方日報》東方文薈版2017年10月29日

撥款不足拖累「全球最佳醫療系統」

預算撥款直接影響公共衛生和醫療護理兩大項目的表現。如果衛生部繼續在資源匱乏下操作，基本化驗樣品和醫藥補給撐不到年底就用完的窘境，最後可能變成常態。這不可能是「全世界最佳的醫療系統」的操作方式。一個負責任愛民的政府應當懂得分輕重，知道哪些公共服務應優先，確保財力資源的投入與承諾的長遠政策相符。當2018年度財政預算案揭曉時，期待衛生部能獲得公平合理的撥款，實際反映出其需要；也希望即將來臨的政府總預算不會花得不知所謂，都消耗在明年大選。

【文／林志翰】

記得今年初，首相納吉風光滿面地宣佈馬來西亞擁有全世界最佳的醫療系統，他的憑據是一份國際雜誌International Living月刊的評估，結果遭受網民冷嘲熱諷。這或許反映出國際雜誌對國內公共和私人界醫療的評估，與一般老百姓的實際體驗或印象有著極大落差。納吉這項宣佈也被譏為「一令吉肉雞」般的務虛政治秀。

其實，大部分國人也不怎麼計劃本身的醫療保健事項，更遑論分析醫療政策——只有當病痛找上，才慌張尋找醫療援助。馬來西亞人何其幸運，因為我們的醫療系統是襲自前殖民國英國的貝弗里奇（Beveridge）模式。在這系統裡，政府不但是資方，同時是主要的醫療服務供者，也是公共醫療衛生的策劃者、監管者和執行者。公共衛生是排在國民教育服務之後，政府（幾乎免費）提供且耗資第二高的福利項目。在我國，求醫看病被看成是人民的權利，因為有政府作為靠山。反之對比鄰國新加坡和印尼，較常強調個人對健康的責任，國民更意識到自身的醫保存款、保險金和共同付款（co-payment）金額，是否足夠應付醫療服務的不時之需。

衛生部經常宣稱我國衛生系統是進步（progressive）和扶貧（pro-poor）的，因為公共衛生的財源主要來自一般稅收（我國稅收架構理論上應是越富有的被課稅越多）。這再對比公共醫療的主要使用者是來自最低的40%社會經濟階層人士。我國的共同付款費用價單自1982年以降已不曾調整，如今已幾乎是象征式收費（一令吉看外科，五令吉看專科）。這些收費匯集起來，估計只達政府用在醫療衛生上的2%開支。

至於國人對我國醫療系統有何要求？大概可歸納為：
一、距離合理：醫療設施與居住社區保持在合理距離以內；
二、可負擔：治療費合理並有可能讓家庭負擔得起；
三、有效率：等候期間和治療需時合理，不至於影響病患者的工作和生活；
四、優質護理服務：以最有效和專業的方式治療護理，同時也尊重病患者。

問題是，衛生部是否已準備好充足「銀彈」，憑著長遠全面的策略計劃來提升硬體設施、增加醫療勞動力以及改進醫療服務效率（即提高產量又控制開銷）？

錢要花在刀口上，是一般生意人熟悉不過的概念。政治上何嘗不是如此？財政預算案就是檢驗一個政府對政策的執行誠意，尤其在資源有限下更能體現政府對各政策拿捏的優先態度。

近來，衛生局總監諾希山公佈2016年政府醫院的外科診戶訪次比起2015年高出一千萬，或22%的需求增長率。正因如此，衛生部長蘇巴馬廉埋怨2017年預算案撥款給該部門並不足夠，敦促政府明年撥出更高預算。

醫藥費上升是全球趨勢，國內私人醫療界也感同身受。2017年的《全球醫藥趨向走勢》報告（Global Medical Trend Rates）預測馬來西亞的醫藥通膨率可達12.0%凈成長，是亞洲區的兩倍（6%）。這無形中也給衛生部增加更大壓力，因為今年的預算只見區區7.7%的成長。

據報導，2016年私人醫院病患者訪次下降了20%至30%，只因更多人寧願選擇公共醫療服務。可見私人醫院本身也是醫藥通膨的受害者。近年來政府大力鼓吹醫療旅遊（medical tourism），對外宣稱我國醫藥費多麼的廉宜可負擔，惹惱了不少本國人。早前2015年《國家衛生與病態調查》報告（National Health and Morbidity Survey）顯示，公眾對私人醫療治理收費的印象傾向負面，高達25.9%的全國受訪者直接給予「差勁」（poor）的評分。這說明了國家經濟停滯不前，更多尤其來自中低家庭收入階級者無法負擔私人醫療，更甭說當發生大病急症。奈何在2015年全民醫療開支帳目裡，只有8%的付費來自私人醫療保險，未雨綢繆投保的人口估計少於10%。政府對此責無旁貸，必須準備好在來年迎接更多病人從私人界「回流」到公共診所醫院。

衛生部官員雖常辯稱更多財政資源無法保證醫療服務素質的提升，不過事實上，去年提呈的「縮水」預算直接影響了公共衛生和醫療護理兩大項目的表現，因為絕大部分的物資和服務供應項目皆被大打折扣。試問在這種情況下，醫療服務素質有可能會提升嗎？如果衛生部繼續在資源匱乏下操作，基本化驗樣品和醫藥補給撐不到年底就用完的窘境，最後可能變成常態。這不可能是「全世界最佳的醫療系統」的操作方式。

為了舒緩醫療系統的強大公共需求壓力，政府應助衛生部一臂之力給予更多發展撥款來提升硬體兼軟體設施，尤其是目前擁擠爆棚的大都市政府醫院。自2010年，衛生部的發展撥款卻不增反減，2017年的13.4億令吉更是八年來最低的數額（見表一）。

參考了多項因素包括預估的15%醫藥通膨率、各部門10%至20%的薪金調整，加上預計中更高的人民需求後，衛生部必須爭取到比2017年還多出15%以上的撥款預算。換句話，該部門明年的預算得大於285億令吉才能安心運作。

一個負責任愛民的政府應當懂得分輕重，知道哪些公共服務應優先，確保財力資源的投入與承諾的長遠政策相符。我個人寄望，當2018年度財政預算案揭曉時，衛生部能獲得公平合理的撥款，實際反映出其需要。希望即將來臨的政府總預算不會花得不知所謂，都消耗在明年大選。

刊登于《當代評論》2017年10月10日

Bigger budget health allocation an absolute necessity

WHEN Prime Minister Datuk Seri Najib Razak proudly declared that Malaysia has the best healthcare system worldwide (as rated by a monthly magazine, International Living), many social media users responded to his statement with cynicism. This reaction was perhaps due to the discrepancy between the magazine’s evaluation of public and private healthcare and the reality experienced or perceived by Malaysians.

Most people do not give much thought to planning for their health, let alone healthcare policies, until illness strikes and the need for medical assistance arises. Perhaps we Malaysians do not realise how fortunate we are.

In terms of health systems, our country’s model has inherited the Beveridge model from the UK, in which the government acts as the major healthcare provider and payer in addition to the roles of public health planner, regulator and enforcer.

In this welfare-based system, many Malaysians may have taken their right to health for granted, unlike in Singapore and Indonesia, where individual responsibility is more heavily emphasised. There, citizens are more mindful about their own health savings, insurance premium and co-payments for healthcare services.

Those of us who utilise healthcare services would typically rate the system according to the following factors: (i) Accessibility: whether facilities are located within a proximate distance to their community, (ii) Affordability: whether fees charged are reasonable and in accordance with their household income (iii) Efficiency: the waiting period to receive treatment should be reasonable and not impede the patient’s work and life, and lastly (iv) Quality care: care should be delivered in an effective and professional manner, and the patient treated with respect. 

Our Ministry of Health (MOH) often claims that Malaysia’s health system is progressive and pro-poor, as public health financing is largely derived from general taxation (where the richer get taxed progressively more) and public healthcare majority users are mostly from the lowest two socioeconomic segments (Quantile 1 and 2, poorest 20% and the next 20%) of society. Moreover, co-payment user fees (unrevised since 1982) are extremely nominal (i.e. RM1 for outpatient visit, RM5 for specialist visit). This amounts to approximately 2% revenue collection against healthcare spending.

The crux of the issue is whether the MOH has adequate finances to meet the rising demand, and a holistic long term strategic plan to (i) expand the infrastructure and facilities capacity (ii) increase the health workforce while (iii) improving efficiency of healthcare delivery (i.e. containing cost but increasing productivity).

The global rise of medical costs is being felt in Malaysia’s private health sector too. The 2017 Global Medical Trend Rates report has forecasted Malaysia’s medical inflation rates to experience a 12.0% net increase, twice the Asia net average (6%). This increases pressure on the MOH to contain costs, especially given the mere 7.7% increase in allocation in the 2017 Budget.

Recently, the Director General of Health Dato Dr Noor Hisham Abdullah told the media that “(the MOH hospitals are) seeing an additional 10 million outpatientslast year compared to the 45 million received in 2015”. This number translates to a 22% increase in service demand.

To that end, health minister Datuk Seri S. Subramaniam was right in claiming that the 2017 budget allocation was not enough and to urge for greater resource allocations next year.

Private hospitals are also the victims of rising medical cost. Last year, these hospitals suffered a 20-30% drop in patient volume as more patients opted for public health service. The National Health and Morbidity Survey 2015 found public perception towards treatment charges in private healthcare to be somewhat negative, with 25.9% respondents nationwide giving it a ‘poor’ rating.

An increasing proportion of those from middle and lower household income classes could not afford to utilise private healthcare services, let alone in the event of a catastrophic illness. Out of the total population health expenditure in 2015, only 8% of contributions were made from private insurance. While not entirely conclusive, one may safely assume that under 10% of citizens had private insurance coverage. A greater volume of patients may turn to public health facilities in coming years. The government must be prepared for this increased pressure on health services.

Granted, greater financial resources does not necessarily guarantee an improvement of services; nevertheless, last year’s stretched budget did affect Public Health and Medical Care, with across-the-board reductions for most services and supplies line items.

If MOH still continues to operate under-resourced, the likelihood of basic test materials and medical supplies running out of stock may become a more frequent and familiar scenario. In line with the increasing public demand for healthcare services, more resources should be given to MOH’s development budget to expand the current capacity of the healthcare system as well as to alleviate the current stress in the system.

After considering various adjustment factors such as the forecasted 15% medical inflation rate, typical salary  increases of between 10-20% per department, and a projected higher healthcare demand from the public, the MOH should minimally secure a 15% larger budget allocation compared to what it received last year (in other words, more than RM28.5 billion).

Spending priorities should be to ensure that at the very least, all drugs listed in the National Essential Medicine List (NEML) and basic test reagents are readily available at all times. Furthermore, MOH should channel an appropriate level of funds towards increasing capacity and improving service delivery in all its healthcare facilities, especially in congested urban hospitals.

A responsible government should set its priorities right for the type and amount of public investments to make, to reflect how much they care for the well-being of the people. For this, long-term strategic planning, not firefighting, is the way to go. It is my hope that, when the 2018 Budget is tabled, the MOH receives a fair allocation that matches its needs.

Published at The Malaysian Insight, Voices, Oct 1, 2017.

族群和睦关係省思

话说好几周前，我注意到友人在面书上分享黄明志最新创作的音乐视频（MV），曲名为《阿里阿狗和木都》。若读者有所不知，黄明志是个颇有爭议性的嘻哈艺人。他就曾在10年前推出了一首《Negarakuku》而大红大紫。当时那首歌被批评为反政府、反伊斯兰教、反马来人和污蔑国歌，而他成为了马来右翼份子的箭靶。强烈对比当年那首「成名曲」，《阿里阿狗和木都》非常政治正確地描述我国三大种族，即华巫印裔之间的族群和谐。副歌里更如此唱：「友谊永固，同心同魂（…kawan selama-lamanya，satu hati satu jiwa）」。

我並未质疑黄明志和其他艺人欲通过歌曲与视频释放善意，努力促成族群和睦关係。只是，我们到底如何才能跳脱表面的族群和谐象徵，去回应现实中复杂的课题，尤其是那些造成我国多元种族社会出现互不满意互不信任、无法良好融合相处的矛盾？

多元社群超越三大种族

首先要指出的是，我国的族群和谐画面一般都只强调三大种族的团结。令人詬病的是，这论述遗漏了我国存在的多元社群，比方说半岛的原住民、东马的土著以及混血族群例如峇峇娘惹、欧亚混血人和印华混血人。这样的画面也似乎暗示著这些社群不入主流，只能委屈退居到被边缘化的「lain-lain（其他族群）」类別。虽然身为公民的一份子，这种排斥性的待遇或忽略往往可能造成这些族群的困惑，让他们觉得自己不受国家认同和重视。

联昌国际银行基金会（CIMB Foundation）在今年初发佈了一个有关族群关係的报告，发现有89.5%马来裔、79%华裔和68.7%印裔受访者拥有很多或几乎所有的朋友都来自本身族群。这显示在日常生活中，各族缺乏深入交流。黄明志MV里宣导的阿里、阿狗和木都的故事似乎不是现实常態。捫心自问，究竟有多少MV观赏者其实非常渴望这类的跨族友谊？如果有，那么到底在现实生活中是什么障碍阻止这类友谊建立？

单一源流教育不是捷径

有些人，包括政治人物，似乎把单一源流教育系统的倡议当成有效地拉近我国族群关係的一种万灵丹。上个月，在一场TN50国家转型计划的政治研討会里，巫青团执委沙里尔韩旦（Shahril Hamdan）直言单一源流学校基於「孩子从小就长时间接触交流」，可成为「促进族群团结的方程式」。但，单一源流学校有可能会是他口中所谓促进族群团结的「捷径」，又或者我们该问，这提议理想吗？

或许某些人已忘了（或不认同）我国独特之处和优势正来自多元文化语言的社会背景。这个多元性恰恰正是吸引许多游客慕名而来並爱上我国的原因。我国自我標榜「真正的亚洲（Truly Asia）」，不是偶然的。

前首相阿都拉巴达威曾建议在国小推动母语课程。当时他表示：「我们应该学习友族的语言，根据需求与时並进」。纵然当时的政府可能拥有其他的议程（若搁置母语科师资短缺的问题不谈），这还是个值得讚扬的语文政策。政府可参考多元语言国家如加拿大和瑞士落实双语政策。孩童们必须学习两个主要的国家语言；前者学习英语和法语，后者则是德语和法语。

语言不应成为障碍

別误会，我全力支持不同源流的学生增加交流互动的机会。这是正面的行动，应该鼓励和表扬。语言不应成为不同族群学生们的交流障碍，因为国民型学校的学生也学习马来文。

即便如此，我仍坚信仅仅语言无法確保族群和谐，尤其是当国民仍根据肤色和宗教被赋予不同的差別待遇和权利。即使学校孩童共用一室，他们仍经常意识到或被提醒自己与他人的不同。近年来就有两宗案例印证问题的纠结：其一是非穆斯林学生被迫在斋月期间在洗手间进食用餐，其二是在另一所国民学校连杯子也被区分为穆斯林和非穆斯林专用杯。

没错，没有孩子一出生就是种族主义者。然而在孩子的成长过程中，在耳濡目染下得到的讯息会影响他们如何看待事物。某些族群偏见可能因此渗透年轻人的思想，进而形成族群歧视的根源。有鉴於此，政府和社会应创造一个优良有利的环境，让孩子们从小就能有积极正面的观念与各族同胞做朋友。

检討积极平权措施

积极平权措施（Positive affirmative action）是一个全世界普遍实践的政策。如果执行妥当，它拥有巨大潜能达到社会正义的目標。因此，积极平权措施应专注於把资源导向最符合资格寻求援助的个人。

一般上主流的积极平权措施是根据阶级作分配资源，虽然在某些国家的少数民族（例如原住民族群）也可享有优惠待遇。

一旦积极平权措施被滥用和扭曲，那些没受惠的人民难免会深感不满，觉得这措施毫无社会正义可言。在我国，或许有些人会认为自己被贬至「次等」公民，不满其他人基於肤色和宗教身份就可享有更多的优惠权利。如此的不满情绪或可酝酿很久並传给下一代。若政府和社会不认真看待，日后这將会是颗计时炸弹，会一再出现令人难堪或不安的衝突。不公平待遇的印象若被默许持续下去，这將会是国民团结精神、跨族群的信任和相互接受的重大障碍。

政府与议员们应不时检討我国现行的政策、法律和宪法，並积极地確保这些条文都能符合「自由、平等和博爱」的普世价值观。若没採取实际行动处理人民的不满根源，再多的表面跨族和谐画面会有用吗？到底何时马来西亚人方可接纳各自不同的身份背景，並得以平等公民自居、共享这片土地？

刊登于《東方日報》東方文薈版2017年9月2日

Reflections on racial harmony in Malaysia

WEEKS ago, I noticed on my Facebook feed that some friends were sharing the latest music video produced and composed by Namewee, entitled “Ali, AhKao dan Muthu”. Namewee is a controversial hip-hop artist who was once condemned by Malay right-wing groups following the release of “Negarakuku” 10 years ago. His song carried some anti-government undertones, and he was accused of disrespecting Islam, the Malay race and insulting the national anthem.

In stark contrast to his previous song, “Ali, AhKao dan Muthu” is a politically-correct portrayal of racial harmony among the three main ethnic groups in Malaysia, namely Malay, Chinese and Indian. Its chorus goes “…kawan selama-lamanya, satu hati satu jiwa”.

While I do not dispute Namewee’s well-meaning intentions (and indeed that of other artistes) who are working hard to promote interracial harmony via songs and videos, how can one transcend stereotypical symbolism of interracial harmony to address the elephant in the room – the real complicated issues that create discordance, mistrust and discontent among the multiracial community?

Firstly, racial harmony in Malaysia typically emphasises the unity of only three major races, leaving out diverse communities, for example, the aboriginals (or ‘Orang Asal’) in Peninsular Malaysia, the native bumiputera in East Malaysia and mixed parentage groups such as baba-nyonya, Eurasian and Chindian, as if they do not fit into the whole picture but only the fringe ‘lain-lain’ position. These groups might feel disconnected or disillusioned at being excluded.

Secondly, a study on interracial relations published by CIMB Foundation on January 2017 found that 89.5% Malay, 79.0% Chinese, 68.7% Indian respondents reported having a lot or almost all of their friends from their own racial groups, pointing to a lack of deeper racial interactions on a daily basis.

This is indeed a disturbing reality, and one that contradicts the “Ali, AhKao dan Muthu” friendship propagated by Namewee’s video. The question we must ask ourselves is this: how many Malaysians actually desire such inter-racial friendships, and if they do, what are the real life obstacles that prevent these relationships from forming?

Certain people, including politicians, have alluded to the single-stream schooling system as the magical silver bullet that will bolster interracial harmony in Malaysia. Some weeks ago, during a TN50x session on politics, UMNO Youth exco Shahril Hamdan claimed that having single stream schools could be “the formula to achieve unity among races” based on “constant engagement with one another from a young age”. But is this “short cut” to promote unity, as he claimed, really something desirable?

People often forget that Malaysia’s strength lies in the diversity of our multicultural-multilingual plural society. This diversity is very reason why so many travellers, from near and far, fall in love with our country – a country that is indeed a Truly Asia, a well-known international recognition.

The former Prime Minister Abdullah Ahmad Badawi once proposed to introduce ‘home language’ classes in national schools.

"We should be learning the languages of other races in line with today's needs," he said.

Although the then government had other motives for that proposal (and if we disregard the issue of shortage in mother tongue language teachers), it was nevertheless a praiseworthy policy proposal mirroring language policies practiced in other multi-lingual countries such as Canada and Switzerland. In those countries, children are made to learn dual major languages in school (English and French for the former; German and French for the latter).

Make no mistake, I am all for students from different backgrounds coming together and interacting more frequently with each other. Such positive actions should be strongly encouraged, moreover language should not be the barrier since vernacular school students are taught in Bahasa Malaysia too.

Still, I argue that language alone will not guarantee racial harmony especially not when Malaysians are still accorded different treatments and rights based on their race and religion. Even if school children were to share a classroom, they would still be constantly aware and reminded of how different each is to other.

One need only recall the incident when poor non-Muslim students had to eat and drink in the restroom during Ramadan, or, in another case how cups were separated according to Muslim and non-Muslim in another national school.

It is true that “no child is born a racist”. Some years ago, a documentary produced by local filmmaker Jason Lim showed that as children grow up, the messages they receive from the surrounding environment shapes and influences the way they perceive things.

Under adverse circumstances, certain racial stereotypes could infiltrate young minds, forming the basis for discrimination. The government and society should do more to cultivate a good environment for children to form multiracial friendships from a young age.

Positive affirmative action is an accepted worldwide practice. When applied appropriately, it holds much potential to reach the goal of delivering social justice. However, to attain that goal, policies for positive affirmative action should focus on channelling resources towards qualified individuals who need the assistance the most.

Class-based positive affirmative action is usually the mainstay, though in certain countries the absolute minorities (e.g. aboriginal tribal communities) do enjoy certain preferential treatment. The abuse and distortion of affirmative action creates social injustice and unhappiness for those who are non-beneficiaries of the system.

In Malaysia, certain quarters might feel they are rightly or wrongfully treated as ‘second class’ citizens, and perceive that some enjoy more privileges and opportunities than themselves. Such sentiment could brew over a long time and pass down through generations if nothing is done to weed out the roots of this dissatisfaction stemming from differential treatment according to racial and religious lines.

Left unchecked, it could even erupt into ugly (not necessarily violent) conflicts. Such cases have already unfolded now and then in our country. If the perception of unfairness is allowed to persist, it would be a real stumbling block to realise the true spirit of national unity, trust and mutual acceptance among various ethnicities in Malaysia.

The government and lawmakers must periodically re-examine our existing policies, laws and constitution, and strive to ensure that these reflect the universal values of liberty, equality and fraternity.

What use is there in propagating a superficial rhetoric of interracial harmony, if no concrete action is taken to deal with the underlying causes of dissatisfaction among the grassroots? When will Malaysians be able to embrace their different identities and daily practices, yet be treated as equal citizens sharing this land? 

Published at The Malaysian Insight, Voices, Aug 28, 2017.

谁该为您的健康负责？

標题的答案似乎已呼之欲出。在正常的情况下，大部分人都可能这样答：当然是自己啦！。事与愿违，现实里很多人言行不一致，並没有好好照顾自己的健康。常人说：预防胜于治疗。如果国人都认真地遵照这常理智慧，那么政府在公共卫生和財政规划方面就轻鬆多了。

现实是残酷的。2015年度的《国家卫生和病情调查报告》（National Health and Morbidity Survey 2015）显示，有30%的大马人口超重（overweight），再有17.7%的人过胖（obese）。换言之，若按照世界卫生组织1998年的体重指数（BMI）指南標准，接近半数的大马人口拥有不健康的身形。若根据大马临床实践指南標准，不健康身形人口的比率更高，逼近2/3人口（64%）。

不爱运动爱美食

其中的问题是，国人不爱运动。如果依据《国际体力活动调查问卷》（IPAQ）的定义，估计有33.5%人口被鉴定为「非活跃」的。其实该问卷对于「活跃」的標准要求並不高，如国人能至少每週有5天每日步行超过半小时，或进行中等激烈的运动。然而，1/3的国人连这点都办不到。

不健康的饮食习惯与患上非传染性疾病的偏高风险息息相关。其中泰勒大学2014年的研究发现有64.1%的国人至少每天都在外吃一餐，同时又有31.9%的人习惯在晚餐后仍进食一餐高份量的饮食。

不少大马人常以马来西亚是美食天堂为借口，说这里拥有太多难以抗拒的美食怎能不多吃？那看似有道理，但放眼全世界再检视这说法，就可发现其实美食与肥胖並没有直接关联。
倘若属实，美国和英国其中这两个世界上最胖的国度应同时拥有最多最好吃的美食，何时轮到被公认为西方美食国度意大利和法国呢？看看泰国和印尼，两国的美食也可媲美大马一样载誉全球，却在肥胖国度的排位上低于我国，那又是为何呢？

公共健康危机

社会无法不重视缺乏运动和不健康饮食习惯对公共卫生所带来的严重祸害。仅仅是非传染性疾病病例，已佔据了大马73%的死亡人口。在2012年，至少有70%的大马人被诊断患上非传染性疾病。在2015年，涉及到呼吸管道、心臟血管、消化系统、泌尿生殖系统和癌症相关的非传染性疾病都挤上了十大入院的病例种类排名，病例总数为120万次。

就仅谈治疗糖尿病的花费，估计已达国家卫生预算的16%。2014年一份卫生部报告统计显示，若综合所有的直接和间接费用，政府需为每名糖尿病患者每年支出3750令吉充作治疗费。

那么，健康问题是否该全怪个人没照顾好自己，而政府就可以置身度外，对確保社区国民健康事宜毫无责任？非也，本人不这么认为。

政府难以推搪

大马政府已有很多宣传管道可整合设计出有效的推广健康运动，包括使用本身和官联公司旗下的电台、电视台以及纸媒。提倡活跃能动生活和良好饮食习惯，若在政府有效的宣传指挥下必能事半功倍。可惜，我们在日常生活体验到的反而是连环轰炸的各类快餐广告出现在各大电视台、电台、报纸和宣传看板上。政府其实可创意地鼓吹健康饮食文化，例如把健康讯息置入流行动画例如本地製作的《Upin dan Ipin》，让孩童从小就接触到正面的健康资讯培养良好习惯。学校食堂的饮食选项和营养更不可忽略，尤其是要阻止一些食堂经营者售卖太油或太甜的食物给学生。

至于小学和中学的体育课，我国政府仅安排每週80分钟，被拋于多个区域国家之后：新加坡和韩国拨出每週120分钟、中国105-135分钟，日本则是125-130分钟。问题在于我国的体育课鲜少被重视，只因它不是考试科。家长也应以身作则带领孩子走出並接触户外，以培养热爱运动的习惯。那么户外活动总需要个空间吧？

到了最后，从城市规划的角度来看，政府的责任更难以推搪。政府应根据人口密集度提供足够大小的公园和休閒空间，特別是在稠密的城市地区。据国家城市化政策下的標准，每1000人应享有2公顷的公共空间。地方政府应鼓励人民多步行和骑脚车，所以当务之急是改善行人道和脚车道的衔接网络。那么，能「动起来」的人民或许会更愿意使用公共交通，捨弃私家车。

总而言之，在改变社会行为以达至更好的公共卫生结果的角色上，政府其实能做的还有很多。但人民本身也该回应政府的呼吁，尽本分照顾自己的健康。若双方都配合得体，我国绝对能减少公共卫生和健康问题，那么或许再也不会有人说大马美食和健康不能兼得。

刊登于《東方日報》東方文薈版2017年7月22日

Who is responsible for your health?

The question seems like a no-brainer. Under normal circumstances, the answer is most likely ‘our own good self’.  But in reality, some people do not take care of their health as well as we would like to think. The common wisdom is ‘Prevention is better than cure’; if every Malaysian took this axiom seriously, it would surely ease the task of the government in terms of public health and financing.

The reality is stark. The National Health and Morbidity Survey 2015 recently showed that 30% of the Malaysian population is overweight, while a further 17.7% are obese. In other words, nearly half of the Malaysian population was found to have an unhealthy body size based on the World Health Organisation’s (1998) Body Mass Index (BMI) guidelines. The percentage goes even higher, at 64%, if we are to use the Malaysian Clinical Practice Guidelines).

Based on the definition given by the International Physical Activity Questionnaire (IPAQ), 33.5% of the population is identified as ‘inactive’. This is unsurprising news, given that one third of the Malaysian population do not practise moderate intensity level of physical activity such as walking for more than 30 minutes per day for minimally five days a week.

Unhealthy dietary practice is correlated with a higher risk of non-communicable diseases (NCDs). A study found that 64.1% Malaysian individuals eat at least one meal per day outside of the home daily, while 31.9% habitually eat a heavy meal after dinner.

As a natural defence, many Malaysians would be quick to claim that Malaysia has too much irresistable good food. But contrary to popular belief, there is no correlation between good food and obesity. If that were true, then countries such as the United States and Britain, two countries that currently top the obesity rankings, should also top the world for the best food, instead of countries renowned for their culinary fare such as Italy and France! On a more regional note, Thailand and Indonesia, countries which have equally tempting food choices as Malaysia, are in fact ranked lower than our country in the obesity rankings.

Society cannot afford to ignore the serious consequence of lack of exercise and bad eating habits to public health. NCDs are responsible for 73% of deaths among Malaysians. In 2012, at least 70% of Malaysians were diagnosed with NCDs. As of 2015, NCDs in respiratory, circulatory, digestive and genitourinary systems as well as neoplasms (cancer) made it to the top 10 principal causes of hospitalisation, totalling 1.2 million cases. The cost of treatment for diabetes alone is estimated to account for 16% of the national Malaysian healthcare budget, while the combined direct and indirect per-patient costs for diabetes was found to be RM3,750 in 2014.

Yet, is it right to place the blame solely on the individual, and claim that the government plays no role in attaining good health outcomes in the communities? I do not think so.

The Malaysian government has many tools at their disposal to coordinate effective health promotion, including TV and radio channels as well as newspaper press. These are effective channels through which the government can encourage active lifestyle and good dietary habits among society. These days, we are constantly bombarded by various fast food advertisements on TV, radio, newspaper and billboards. Perhaps the government should emulate the US Food and Drug Agency (USFDA) in regulating food providers, especially fast food outlets, to have compulsory nutritional list on their standard menus.

The government could also come up with creative ways to encourage healthy eating habits using commercial activities. For example, the use of popular animation series such as “Sesame Street” or the locally produced “Upin dan Ipin” to promote good eating habits and encouraging physical exercise could potentially lead to a shift in lifestyle habits among minors, and further reduction in NCDs.

School-based nutrition plays a great role in altering social norms and behaviours. It is not helpful if some school canteen operators could get away with selling foods which are either too oily or too sweet. Current programmes involving poor students such as “Rancangan Makanan Tambahan untuk Pelajar Miskin” are a good platform to educate canteen and cafeteria providers on the importance of including more nutritious food items in their menu. The sale of junk food should be banned if they follow the guidelines set by the government.

In terms of physical education in primary and secondary schools, the government allocates just 80 minutes per week. We are lagging behind other countries in the region – Singapore and South Korea both allocate 120 minutes, China, 105-135 minutes, and Japan, 125-130 minutes. In Malaysia, physical education is seldom prioritised because it is perceived as less important than studying and passing for examinations.

While there has been an increase in the number of running and cycling events in the Klang Valley, such events should be encouraged in other states in the country and younger participants should be encouraged to participate. Parents need to lead by example, by teaching their children to love physical activities . This could be done through enrolling them in running clubs, frequently enjoying indoor or outdoor sports as a family, and limiting screen or internet time so as to encourage outdoor activities.

Finally, from an urban planning perspective, the government must provide sufficient parks and recreational spaces per population density, especially in the urban areas. Local governments can encourage higher activity levels by improving the connectivity of pedestrian walkways and cycling paths, and encouraging the use of public transportation over that of private cars.

In conclusion, there is plenty that the government can do to shape desirable social behaviours towards better public health outcomes. But society, too, must do its part by responding to these calls. If both play their roles right, Malaysia will surely be on the right track to reducing public health issues and living up to the mantra of “prevention is better than cure”. 

Published at The Malaysian Insight, Voices, July 9, 2017.